Provider Demographics
NPI:1538282371
Name:BERACHAH VALLEY CORPORATION
Entity Type:Organization
Organization Name:BERACHAH VALLEY CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:PHILLIS
Authorized Official - Middle Name:CREEK
Authorized Official - Last Name:BURRESS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-757-9718
Mailing Address - Street 1:PO BOX 296
Mailing Address - Street 2:
Mailing Address - City:FERRIDAY
Mailing Address - State:LA
Mailing Address - Zip Code:71334-0296
Mailing Address - Country:US
Mailing Address - Phone:318-757-9718
Mailing Address - Fax:318-757-0144
Practice Address - Street 1:1619 CAMELLIA ST
Practice Address - Street 2:
Practice Address - City:VIDALIA
Practice Address - State:LA
Practice Address - Zip Code:71373-3803
Practice Address - Country:US
Practice Address - Phone:318-757-9718
Practice Address - Fax:318-757-0144
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA117293747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care AttendantGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1191051Medicaid